371 – Women’s sexual health: desire, arousal, and orgasms, navigating perimenopause, and more

Hey everyone, welcome to the Drive

podcast. I'm your host Peter Aia.

[Music]

Sally, thank you so much for coming out

to Austin.

>> Thank you for having me.

>> This is a topic that on the surface

might seem somewhat directed towards 50%

of the population, but I think it's safe

to say it's probably going to be

directed towards 100% of the population.

Um,

so you have a practice, you're an OBGYn,

but your focus is not just on maybe the

standard OBGYn things, but really around

women's sexual health. Is that a fair

assessment?

>> That would be a fair assessment. Yes.

From a hormonal and physiologic

perspective. Yes.

>> Awesome. Well, by way of background, we

were introduced through uh a mutual uh

friend/patient

um who had listened to the Rachel Rubin

podcast that I did uh recently was super

impressed by it and said, "You have got

to speak with Sally." And one thing led

to another and we are now speaking. So,

um, let's start by helping people

understand why would a podcast that

focuses on health, longevity,

all of these things that pertain to

living longer and and better. Why would

sex be an important part of that

discussion?

>> Well, I'm having a hard time

understanding how sex couldn't be a part

of that conversation. Um, I think you

know, first of all, this is a

performancedriven podcast. And so for

the 50% of your listeners who are male,

if you want to improve your performance,

I'm going to give you facts and

anatomical descriptions. Um, and

describe some pathophysiology so that

you can improve your performance. Um,

this is clearly sexual health is health.

And when you look at your longevity

levers and you think about your

centinarian decathlon and what you want

to do when you're 100, for many people,

this is on the list and I want to talk

about how to structure your life and get

you ready to do that. Um, I also think

that there's probably a small group of

listeners similar to myself who always

thought that the drive was supposed to

be about sex drive and that you just had

a branding uh error when you named it

the drive. So for those people as well,

I we're finally going to talk about the

drive that you actually care about um

which is sex drive.

>> So um there's there's a lot to sort of

unpack there, but I think I want to kind

of go back and talk a little bit about

something you said visav um the actual

health component of this, right? So

if you if you if you if you looked at

this through the lens of just evolution,

everybody clearly understands why sex is

important and it's the single most

important thing in the propagation of

our species, but can you say a little

bit more about how it actually factors

into health? Um, and I don't just mean

emotional and mental health where I

think we could easily make that

connection. Is there any evidence

whatsoever that a healthy sex life plays

a direct role in in health as it

pertains to disease?

>> Definitely. I'll start out with my two

caveats though, which is one, this is an

underststudied, underinvestigated area

of our health. That's part of my

messaging today. So many of the studies

that I'll reference are not going to be

robust in in volume. Um, and second,

this is a incredibly heteronormative

conversation for that reason. This is a

data-driven podcast and I don't have a

lot of data on non-heteronormative,

meaning men who identify as men, having

sex with women who identify as women.

Um, so that should alarm you as well

that we don't have that data, but that's

sort of the space in which if we're

going to stay in a data rich zone,

that's where we have to stay. Um, and

also the discrepancy when you look at

sexual health is greatest among those

two participants. Um when we look at

sexual health and we try to make the

argument that sexual health is health is

a part of health. Um you know we can

sort of use your longevity framework if

we start with sleep. There is great

data. We know that when you are sexually

active with or without orgasm just

participation in a sexual activity you

switch from sympathetic to

parasympathetic. So post orgasm you have

a great activation of the

parasympathetic nervous system. you

release neurotransmitters, dopamine,

oxytocin. These are relaxing

neurotransmitters. And when we study it

either via diary or via there's great

studies that look at resting heart rate,

sleep latency, many of the measurements

that we look to in terms of looking at

sleep efficiency and quality

subjectively and objectively improve

with intercourse. What's really

interesting and why I want to pull in

all listeners, not just 50%, is there

was a great trial that looked at how

women slept after an orgasm with

themselves and they slept better. And

then it looked at women being intimate

with a man and they slept better. But

women being intimate with a man and

having an orgasm with that man

synergistically improved their sleep.

You're getting sort of a dual benefit of

that neuro pharmarmacology that you're

releasing from your brain, improving

your biometrics, but also there's a

connection and intimacy, a partnership

that we know fosters better sleep.

Cardiovascular health, this is also, you

know, limited. We don't have tons, but

we know that sex can mimic a lot of the

pathophysiology that we experience

during exercise. There's been arguments

over the decades about is it low

intensity, is it moderate intensity? I

think it depends on the couple. Um but

we have studies that have tried to

measure the mets or the metabolic

equivalence or essentially the the

energy output for women on average it's

around uh six to seven metabolic um

units for every sexual encounter. It's

about 60 to 70 calories used during

sexual activity. And there's a great

study that compared this to walking

slowly on a treadmill for the same

amount of time. And they said that

although sex was slightly lower in your

energy export than walking on the

treadmill, many of the participants

reported that they had a much better

time having sex than they did walking on

the treadmill. And so it's still

something to consider. We know the sort

of tapping into the body's natural

pharmarmacology, thinking about

neurotransmitters and the sort of

positive impact on mood and

relationships. Um

it's really interesting to think about

from a relationship perspective. I think

what I don't want to say, what I don't

believe is that everyone has to have

lots of sex and that's, you know, sort

of uh and that there's a number that

we're trying to target. Is there a

number needed to treat? Is there a dose

that we're trying to go for? No, there's

no studies on that. But I also don't

believe that. Every person, every couple

is different. When you look at couples,

um I like to look at sort of who's

having sex and by what frequency. Um,

and so about 20% of couples, and this is

ages 30 to 60, about 20% of couples are

having sex twice a week or more. About

10% of couples are what we call never

having sex. And that means in the last

year and about 70% of couples are having

sex between those, meaning once a month,

twice a month, sort of around that

number. When you look at risk factor for

divorce, it's the same across all

numbers in the sense that it doesn't

matter how much sex you're having. You

could never have sex or you could have

lots of sex. The divorce risk factor is

what we call sexual desire discordance

or one partner wants more

>> and one partner wants less. And so

identifying that as the risk factor, I

hope gives people sort of affirmation or

interest in the fact that if you want to

work on it, I will help you. But not

everyone has to. This is not a podcast

about everyone needs to go work on their

sexy. If you do, I'll sort of go through

the normal pathophysiology and some

additional tips and tricks to help you

have a a healthier sex life.

>> All right. So, two things I just want to

reiterate that you've said that that are

both important and at least interesting

to me. One is um discordance of desire

is a much bigger risk factor than

anywhere you lie on the distribution of

if I recall 10% of people are basically

asexual. 20% of couples uh is it 10% of

couples 20% of couples are at twice a

week or greater and basically twothirds

of couples are somewhere in between. So

that's very interesting. The second

thing you said I can't resist coming

back to the centinarian to Kathon. I'm

glad you brought it up because it is one

of the items on our list on the

framework that we we hand to patients

when we ask patients to pick the 10 most

important things that they want to be

able to do in their marginal decade in

the last decade of their life. Um, and I

would say about twothirds of our

patients select having sex as one of

those 10 activities. That says something

given that we're giving people a list of

about 150 things to choose from, all of

which are quite uh tempting. Um, and to

go back to your point about METS, if

seven METs is what is required

energetically to have sex, we can

convert that into V2. So seven mets

translates to about a V2 of 25

milliliters per kilogram per minute.

Which means if you want to be able to

have sex in your marginal decade, you

need to have a V2 max of probably about

30 milliliters per kilogram per minute.

Why? Because it would be pretty tough to

have sex if you were doing it right at

your maximum V2. That would be like me

asking you to do the fastest 800 meter

run you've ever done and bring that

level of exertion to sex. You got to be

a little bit below your limit. And while

most adults can easily muster a V2 max

of 30 milliliters per kilogram per

minute, if you want to be able to

achieve that in your 80s or 90s when

you're my age or your age, you're a lot

younger than me, you need to be probably

north of 45 or 50. So, if I could just

make one more shameless plug for having

a high V2 max, it's going to allow you

to be sexually active in the last decade

of your life. And I think in addition to

that, it would be great if at the end of

this we had a list of a few sort of

action items in addition to a minimal V2

max that we could consider a toolkit in

order to get this action as something

that's actually attainable on your

centinarian list.

>> Let's talk a little bit about well let

me ask a very silly question. Um when it

comes to understanding what an orgasm

means for a man, it seems relatively

straightforward in that it's tied to

ejaculation. And while there are

examples where a man can have a

retrograde ejaculation due to example

the use of medication and he can still

have an orgasm but you're not actually

witnessing an ejaculation. Um with with

women how is an orgasm actually defined?

Is it a biochemical response in the

brain? Is it a muscular contraction in

the body? Help me and help us understand

that.

>> I think it's important to say that we're

going to talk about normal things. Um,

yes, there's a lot of pathophysiology

and deviations to what's normal and you

should see a doctor and we can talk to

you about it. But similar to sort of

your focus on what's normal in men to

describe what's most normal in women is

a rhythmic contraction of the pelvic

floor muscles. Um, it is there's four

stages um to an orgasm. It starts with

the excitement phase which is an

engorgment of the pelvic tissues.

There's increased blood flow. There's

lubrication released by the skins glands

and other glands of the vaginal canal.

Then there's a plateau phase that is

predominantly a neurotransmitter phase

and a hormone release phase. You can

stay in that for a variety of time

periods. It's person and partnership

dependent. There's the orgasm. Then

there's the resolution phase. And these

four stages, understanding how they work

and where you are in that stage can

allow for the introduction of

interventions that can improve your

sexual life or help you foster a

healthier life in general.

>> What is the period of time in which a

woman will go from those first to fourth

phases? Again, I realize there's going

to be a lot of variation, but what would

be sort of considered interquartile

range of that transit?

>> So, it really depends. Um, when women

are on their own, it's the average time

to orgasm is less than four minutes. And

when women are with a partner, it's

upwards of like 21 to 25 minutes.

>> Question there. Um, with a partner, you

could still have it manual, you could to

be oral, it could be intercourse. So,

how much does that

>> really skews the data? Um, I don't have

the numbers on that. I don't think we

have that. and women are actually

individually so different as well.

>> An interesting takeaway from from your

interest in looking at those numbers is

to think about a statistic we do know

which is that foreplay lasting greater

than 21 minutes over 90% of women

orgasm. So it's it's really sort of

interesting and enlightening to think

about oh gosh so so time actually does

matter in that stage and and and why do

we care about foreplay? What's happening

during that time? That's, you know, sort

of when you're in the excitement phase,

building up towards orgasm, so blood is

flowing to the area. So, we think about

your anatomy changes. So, the vagina

that's usually like 3 and 1 half by 9,

so 3 and 1 half inches wide by 9 in

deep, um, will actually get longer and

wider. And why do we care? 30% of women

will experience pain with intercourse.

So, actually appropriate foreplay where

the vagina not only gets wider and

longer, um, but actually the angle of

the vagina changes. And I think this is

something that I love talking to couples

about because I have many women who will

say, you know, my partner loves this

position and often it's a deep

penetration position. Um, but it really

hurts me. And I say, well, how much

foreplay is going on? And so if there's

not enough foreplay, you don't actually

change the angle of the vagina or change

the angle of the canal. Um, and so you

will experience more pain. You'll have

the tightness of the pelvic floor

muscles and pain fosters pain. You can

get into a pain cycle. And so actually

appropriate amount of foreplay allowing

the angle of the vagina to to change can

allow women to participate in positions

most commonly we call doggy style or

sort of deeper penetration positions

which can then be sort of a part of your

repertoire if you're interested in that.

>> So what about just kind of the

differences in ability to achieve orgasm

the so-called orgasm gap? What what can

you tell us about that? I hope I've

proven to you that sexual health,

pleasure, orgasms are a part of health.

And so I think when we then look at the

disparities and how different parties

will participate or receive enjoyment

out of these activities, I hope it

highlights to you how important it is

that we work on this. And so I'm gonna

quiz you now, which is what percent of

men do you think report when they're

having sex with a woman report that they

almost every time have an orgasm?

>> 95%.

>> 95%. And what about women?

>> Uh, what percentage of women would

report always being able to have an

orgasm with a male partner?

>> Correct.

>> 50%.

>> 30%. And what about for a one night

stand? What percent of women are having

orgasms on one night stands with men?

>> Well, if it's 30% on a regular basis, I

would say

10 to 20%.

>> Yeah, it's around 12%.

And so,

>> what about men at one night stands?

Still 95%.

>> Correct. 90 actually, I should say. It's

90%. Um,

and so when we think about the orgasm,

so if I've proven to you that sexual

health is health, and if we understand

that orgasm is one metric that we can

use, it's not the end all beall. Um,

there's other sort of satisfaction,

intimacy, connection, pleasure benefits

that women get out of intercourse, but

this is one numeric finding that we can

track. Um, this disparity or this

discrepancy is a big deal. And this this

disparity in how women experience

pleasure becomes a health disparity

because if sexual health is health and

women are not experiencing it with the

same amount of pleasure that men are,

this is a health disparity.

>> By the way, within

women, do does orgasm at all correlate

with underlying health?

>> Yes. Um we do we see that we know that

orgasm is related to strength of the

pelvic floor, vascular blood supply. So

there are issues. So there's a lot of

sort of birectional, you know, if you're

healthy enough to be able to have an

orgasm, then you can have an orgasm. And

if you're having orgasms, you're likely

healthier. So there's a lot to that

>> and we know that birectionality, but I

think still looking at the numbers. I'm

hoping that you're thinking, my gosh,

this is this matters. This is a big

deal. We should, you know, we

classically think about sexual health as

sort of an afterthought. When we think

about longevity, we think about cancer

screening and prevention and chronic

diseases and now sleep and exercise. And

once we've sort of addressed all of

those, we now have the luxury of

addressing sexual health. And I just

think we should put it a little higher

on the list.

>> Okay. So, let's talk a little bit more

about foreplay. I I when I think when

most people hear foreplay, they assume

what? Anything that is sexual shy of

intercourse. How do we define foreplay?

Great question. Um, there's medical uh

definitions of foreplay and social. So,

social definitions tend to say anything

outside of penetrative intercourse. Um,

medical definitions rely more on the

physiologic changes that are happening

in your body. Um, increased blood flow,

um, recruitment of uh, swelling of the

clitoreral nerve, um, physiologic

signals from your brain that sort of

prepare you emotionally to participate

in this interaction. Um,

what's most interesting to me about this

is when we think about sort of, let's

start with desire. When we think about

desire, we think of more of the

spontaneous desire. Spontaneous desire

is more common in men. Spontaneous

desire is only present in about 15% of

women. Women have what we call is

responsive uh desire.

>> So, sorry, just help me understand that.

Oh, you were just about to explain

spontaneous.

>> Yeah. So, spontaneous desire is um

you've been married for 20 years. You

see your partner get out of the shower

for the 8,845th

time, and you think to yourself, gosh, I

would love to be intimate with this

person. That's spontaneous desire.

That's sort of desire in anticipation of

intimacy.

Responsive desire is you see your

partner and get out of the shower for

the 8,645th time and you think, "Did I

sign up for the right treadmill tomorrow

morning at 6:00 a.m.?" And that's

because your brain's just not there.

It's not in the same place as your

partner. But if your partner comes over

and starts to rub your shoulders and rub

your feet or maybe has made dinner, um

we call chore play, which is where sort

of emotional uh investments in the

relationship can sometimes lead to to

responsive desire. um using lubrication

um and we'll talk about how to use lube

using a vibrator sort of creating an

environment in which you are capable of

being aroused. That's responsive desire.

And thinking about what's happening in

that circumstance can be really helpful

and validating for women and it can help

their partners get them there too with

the ultimate goal of sort of being

aligned in your sexual desire

from a frequency perspective. And so

you're saying it's

more typical that men experience

spontaneous desire where arousal comes

on in a moment

>> in anticipation.

>> In anticipation and often based on

perhaps a visual cue.

>> Correct.

>> For women that is less common.

>> Correct.

>> But not implausible.

>> Correct. And so acknowledging that

there's a few sort of lessons that we

can take from that. Um, the first is if

you're listening to this podcast and you

want to work on your desire, if you're

waiting for your husband to get a new

shirt or a new Selby or anything, it the

visual stimulus is not evidence-based.

Stop waiting for that. I want you to

think about

>> What about getting a new car? Is that

>> I'd love one, but no. Um, but just to be

clear, I would love one. Um, I want you

to think about how you get responsive

desire in response to arousal. And how

we do that is lubrication. So we know

how to use lube. Most of us do. You're

in the act. You take some lubricant. You

put it on the penis. You put it on the

vagina. You have intercourse. Um I want

to sort of encourage you to think about

lube potentially using it 30 minutes

prior to intercourse. So I want you to

take a silicone based lube. And I'll

tell you why in a moment. Um and I want

you to think about using a lube shooter,

which is a little droplet um to take

some of the lube and put it higher up in

the vaginal canal. And then I want you

to read a book, drink a cup of tea, wash

your face. Um, women, as you sort of

alluded to, are less visually stimulated

into into desire. Um, there's great data

that women like to read erotic

literature and there's great apps for

that. Meet Rosie, Dipsia are great

companies that have auditory or

literature porn for women. Um, there's

great data that's there's great data

that mindfulness can work for women. Um

Lori Bradto wrote a book called mind

better sex through mindfulness thinking

about breathing techniques staying

present in the moment. My favorite

strategy for this is to describe to

yourself in your head not allowed what's

happening my breathing is relaxing my

vagina feels wet. Sort of talking

yourself through what's happening from a

pathophysiologic perspective to bring

yourself into the moment. Um but when we

think about how to curate that arousal

essentially what you're doing is showing

up at the party and then seeing what

happens. And there's no expectations

what happens at the party. But Emily

Nagowski, who wrote Come As You Are,

talks about, you know, it's Friday night

and you really want to put on your

bathrobe and watch Love Island, but

instead you're going to go to a party

with your friends because you said you

would and you get there and it's

actually kind of fun. So, you stay and

you have a good you have a good time,

you have a drink, you actually like your

like it when you're there. Um that's the

sort of idea behind curating your own

arous desire through arousal which is

use a vibrator use some lubricant relax

get in the moment start to participate

and if you don't want to obviously

consent is of utmost importance and stop

but if you sort of start participating

and decide that you're happy that you're

there and you like it please stay and

have a good time

>> okay a lot of questions come up when you

said all those things let's start with

the need for lubrication so I very

naively have assumed that women who are

young enough, right, so not even

approaching estrogen withdrawal are not

having an issue with lubrication. Um

that clearly must be incorrect or you

wouldn't be stating this. So what can

you say about um perhaps the differences

in the amount of lubricant and maybe

even just talk a little bit

physiologically about where is this what

what is what is the lube that is

naturally made? Where is it coming from?

uh and what drives variability both

across women and within a given woman's

life or not let's not even talk about it

within her life within a given month or

something like that.

>> You know you're correct with that line

of questioning to sort of assume that

throughout the month women will have

different levels of lubrication. Um

medications can impact lubrication life

age life cycle. There's so many factors

that go into your ability to have the

amount of lubrication that you need in

order to have a comfortable sexual

encounter. This idea that we just use

lube, need lube as we age, I want to

completely dispel. I think the majority

of women need lubrication and should use

it. Um, the reason the way that we sort

of naturally get lube in our vagina is

from a variety of different glands that

work, you know, better or worse. There's

the skins glands that sort of support

the vagina,

>> which are where

>> they're right on either side of the

urethra. And fun fact about this, many

people will have more prolific skins

glands in the sense that they can sort

of shoot the lubrication a little bit

stronger. So when we sort of talk about

women who what we call squirt, it's

actually the skins glands releasing

lubrication in a more aggressive form.

Um there's Bartholins glands that

produce lubrication that are commonly

known uh for their likelihood to

sometimes get clogged and to cause pain.

Um, but there's so much that goes into

lubrication and it's so important

throughout the life stages that the WHO,

the World Health Organization, actually

has guidelines in terms of how to pick

out your lube. And if you're wondering

right now, wow, I never knew that the

WHO cares so much about my sexual life.

That's that's wonderful. Um, they don't.

They care about HIV transmission. and

picking the appropriate lube decreases

microabbrasions, less friction, less

tearing, less HIV transmission. But we

can sort of take this data into the

pleasure world and think about sexual

health and sort of what so what types of

lube should we use? I think is the next

part of that question. Well, actually I

want to go back and ask a different

question which is isn't there sort of a

minax optimization problem around lube

because friction is also part of what is

necessary at least for the male to have

an orgasm. How much does it matter for

the female?

>> Less so. Um friction is f friction

matters less so to women. And let's talk

about the clitoreral nerve anatomy to

answer that question. Um, I I'm gonna

leave this for you as a gift, but I've

>> I'll keep it on my desk.

>> It's pure pure gold. Um, so you may want

to put it um in your safe, but um this

is sort of the anatomy of the clitoris.

And what you're looking at is sort of

what we tend to discuss in terms of

cleral anatomy. Typically we talk about

is the tip of the iceberg or the the

clitoris. But there's um there's the

crew of the clitoris and there's the

vestibule which which is an engorgment

structure when blood comes to the area.

Your labia minora would be here and your

labia majora would be here. This would

make up the vulva. When we think about

the clitoreral nerve, it actually has

two types of nerve fibers in it. One is

a type A nerve fiber and one is type C.

Type A responds to vibration and it

responds to deep pressure and type C

responds to heat and light touching. So

A is vibration and deep pressure and C

is heat and light touching. What's

really interesting about using this to

answer your question is that there's you

don't friction is not a requirement to

hit any of those four metrics and

actually is so significantly associated

with micro tearing and pain with the 30%

of women experiencing pain with

intercourse. I would argue that women

need no friction. Um,

but to think about how that nerve

changes over time is really fascinating

because type A fibers, the vibration and

the deep pressure. They have a myelin

sheath around them. And so they age

better. Nerves protected by a myelin

sheath are more resistant to

degradation.

>> And that's the A fiber.

>> And that's the A fiber. And so I have

women come in to my clinic and they say,

I've been with my partner for 35 years.

We do this position for 6 minutes. it

always works. It's not working. And I

say, "Have you considered using a

vibrator or introducing a vibrator into

your sex life?" And there's a, "Oh, I

don't know if my partner would feel good

about that. I don't want him to make

him." And I sort of say, "This is an

evidence-based intervention

understanding the science of myelin

sheets and nerve degradation. This has

nothing to do with your husband and

nothing to do with your relationship."

>> How would you do that? So if a if a if a

woman comes in and says in this position

it's exactly as you just said when

you're saying introduce a vibrator do

you mean

use it

>> after or before

>> or during?

>> I see. So put the vibrator externally.

>> Externally.

>> Got it.

>> And there's different types of

vibrators. Some are internal. Um but if

you're trying to pick a vibrator that

you want to use when you're with a

partner, buying something like a wand.

So something that sort of has a uh is

long enough that you can reach the

structure in a variety of positions. Um

something Jimmy Jane makes a nice wand.

Um Goop the wand makes a makes a great

great product as well.

>> Did you bring any of these?

>> I you know I uh long discussion with

your staff about what you wanted laid

out on the table and and the netnet was

no.

>> Oh that might have been a strategic

error. I think I think people at least

I'm kind of curious as to what these

products are.

>> Um

>> we'll link to them in show notes.

>> That sounds that sounds great. Um there

are um air pulse vibrators that you can

put on the clitoris. These are sort of

all external vibrators that you can sort

of bring into a partnered encounter to

have an evidence-based way to continue

to achieve orgasm because that is one of

your greatest ways in which you can

continue to be in a healthy sex life.

And again, not to get too graphic, but

just because if I'm asking this

question, I'm sure someone watching this

is, if you're talking about a sexual

position where the man is on top of the

woman and she's using an external

vibrator,

>> does the man also receive some pleasure

from that?

>> He might. And there there are more

strategic ways that you can try to to do

that if the man likes that, but there's

ways that um the man can angle his

pelvis that he doesn't he may or he

doesn't have to. He doesn't feel it. He

doesn't have to. I want to go back to

something about the female ejaculation

that all of that ejaculatory material

seems external.

Uh meaning it's all so so yeah. So how

is the vagina being lubricated inside?

>> So um they've actually studied this. The

Kinsey Institute put um has great

studies where they put cameras um inside

the vagina and they actually watched the

vagina essentially sweats. Um the cells

of the vaginal canal release water

molecules. There's cervical mucus that

also serves as a lubricant as well.

Again, all of these things very

dependent upon hydration and medications

and things like that. So, you can

understand the importance of sort of

making sure it is appropriately

lubricated uh through the use of

external lubricant. But, um but yeah,

there's many different ways. So, the

vagina sweats, the cervical mucus um and

then the glands that that secrete mucus

into the canal.

>> And for women who do experience that

ejaculation, that's perfectly normal. Do

they have control over that? Most people

think that they do not. Um, most people

think they do not in terms of like how

much if you're more hydrated, if you're

more relaxed, but no, in general, people

do not believe that you that it's a

normal physiologic response that you

cannot control.

>> And it doesn't imply a better orgasm.

>> No.

>> Okay. And what was the frequency again

of women who achieve that?

>> Uh, squirting. I actually I don't have

statistics on that. I don't know.

>> Maybe an a helpful thing to do right now

would actually be to go over a little

bit of the um anatomy. And I I see that

you've brought a model that I think will

make it easier um for for everyone to

kind of understand. So um I want to

start by asking when you deal with your

female patients who presumably are much

more familiar with this anatomy than

than men are. What surprises you the

most when a woman comes into your clinic

um and you're taking care of her? What

are you most surprised by in terms of

her lack of knowledge about her own

body? anatomical

lack of education

um from a

>> just literacy

>> lit from a from a um where was the sex

education

did did we have it did we go I mean from

a uh verbiage perspective referring to

the vagina as the vaginal that's the

vaginal canal is the vagina the vulva is

the outside of the vagina there's labia

majora and minora and um all the way

down to the to the clitoreral nerve and

sort of the fact that it has different

different nerve roots. Um, and so if we

think about, you know, looking at this

model, uh, this is sort of if a female

is lying down on her back, that's the

angle that you're looking at. Um, there

was a great study that was done recently

that said that only 41% of Gen Z men

could accurately identify the clitoris

on a pictorial. Um, women, surprisingly,

>> what would that be for Gen X? like how

much of that is a representation of

declining intimacy as as as people are

in younger generations or is that a

general statement of men period?

>> Uh I take from that sex education needs

to get better. I I mean I sort of take

from that the need for better sex

education that's actually anatomical and

not fear-based. And so women as well I

mean most women not all do know about

the clitoreral hood or the which is the

clitoris or the the bulb. Um, that's

what we sort of think about in terms of

the tip of the iceberg.

>> But what women often don't know is that

they have sort of what we call is the

vestibule of the clitoris, which are

these sort of bulblike structures that

can receive engorgment or when there's

an increase in blood flow. And then

there's the crew of the clitoris, which

is these nerve structures that go on

either side of the labia minora. It's a

wishbone like structure. And what's

really fascinating is to sort of

normalize that anatomy can and should

look different. Um there's a great

website called the labia library that

normalizes all different types and sizes

of labia minora and majora. Um but the

wishbone structures are often asymmetric

as well. And so it is quite common for a

woman to experience gater greater

pleasure on one side of the vagina

versus the other. meaning that this

nerve root of the clitoris may be

thicker or more sensitive. There's over

8,000 nerve roots as a part of the

clitoris and there can be more focused

on one side versus the next. And so I I

hope that half of your listeners are

thinking I always wondered why I was a

righty or I always yeah I'm a lefty. But

I I also hope the other 50% are

wondering if you've been with your

partner for a long enough time. I hope

you know if your partner is a righty or

a lefty. Um because there's asymmetry in

how we experience pleasure. Um and then

very interestingly is that there is, you

know, if you're sort of looking at the

uh tip of the clitoris, there's a nerve

root. There's a part that goes sort of

inside the vagina and that's what we

talk about in terms of um social terms,

we talk about the G-spot. And what that

is is it's a branch of the clitoris that

runs along the anterior or the front

part of the vagina. It's um about a

third into the vagina. The best way to

find it is to if you're sort of if a

woman is trying to find it on herself is

to take her dominant hand, middle

finger, stick it as far in as you can

and sort of do a a come hither movement

or sort of movement of the finger

towards the top part of the vaginal

wall. It's easier to find when you're

aroused because there's engorgment of

the ti the tissues. um it feels a little

more ruggated and you'll know that

you're there if you feel a sensation to

to urinate, but if you relax into that,

you you won't. Um and so only about 10%

of women now are able to orgasm from

stimulation of that internal branch of

the clitoreral nerve. There's some data

that shows that with education that can

go up. And so talking to women about how

they can find the anterior branch of

their clitoreral nerve not only allows

them different ways to orgasm um but

also gives them a sense of empowerment

and sort of ownership to sort of talk

their partner through how to sort of

maintain pleasure. Um but for those

people who can't have orgasms from the

inner part of their vagina, the other

90% are having orgasms from external

stimulation of the clitoreral nerve. And

so Dr. Dr. Lauren Striker says, you

know, for the 10% of women who can

orgasm via the G-spot or the anterior

branch, that's great. And she diagnoses

the other 90% who can't orgasm from

stimulation of the internal nerve as

normal. Um, so it's totally normal if

you can't have an orgasm from that part

of the clitoreral nerve, but many women

after hearing this podcast, I hope try

um partners should try. It has a little

bit it has better blood supply than the

tip of the iceberg. And so as we age,

this is one of my favorite techniques um

for women in the permenopause and

menopausal period as their hormones

change and the nerve fiber degrades a

little bit. Teaching women how to have

orgasms from the part of the nerve that

is better interv

blood supply can help maintain pleasure

and help maintain interest in sexual

activity as we age.

>> All right. So when a woman is having

intercourse and maybe for the percentage

of guys might who might not be familiar,

can you point out where the entry to the

vagina is on this model?

>> Yeah. So here's entry to the vagina. Um

of those um there is um there are some

statistics that talk about what women

can what percentage of women can orgasm

simply by having penetrative

intercourse. So um penis here. And

what's interesting is that the distance

of the clitoris to the vaginal opening

is variable. And the shorter the

distance, we they tend to say less than

one inch. The shorter the distance of

the clitoris to the vaginal opening, the

more likely you are to be able to orgasm

um during penetrative intercourse. And

that's because the distance is so short

that the angle of the man's body is sort

of able to stimulate that area. If that

distance is greater, you're less likely

to be able to orgasm simply from

penetrative intercourse. Q. introducing

a vibrator, manual stimulation, etc.

>> So, what percentage of women are able to

intercourse without any stimulatory

vibrator or anything like that from

intercourse?

>> Less than 10%.

>> Wow. So, it's the same number that you

have from the G-spot.

>> Correct.

>> So, if a woman is listening to this and

she's never had an orgasm through

intercourse, she is in the 90%. There's

nothing wrong with her.

>> We would diagnose her as normal. And for

those women out there who are regularly

achieving an orgasm through intercourse,

you're in the minority and

>> or they're doing external more more

likely they're doing external

stimulation of the clitoris. Those those

grave statistics are without any

external manipulation of the clitoris. I

see.

>> So for women who are achieving orgasm

with a partner, it's because they've

identified positions with their

partners. They're using manual

stimulation. They're introducing

vibrators. They've figured out

regardless of distance of clitoris to

vaginal opening, how to stimulate the

clitoris, the external part of the

clitoris. And I like to talk about

anatomy so that patients can sort of

think about their own individual

anatomy, talk to their partners about it

and think about if there's someone who

needs to sort of introduce that external

stimulation or shall they as a couple

try to find the anterior branch of the

clitoreral nerve. There's lots you can

you can do as a part of that. How often

do you have men in your practice who are

there with their female partners who

you're trying to educate

>> for a sexual health consult? 20% of the

time.

>> And what is the most common

um I don't want to use the word

ignorance, but what is the most common

thing that you appreciate about men when

you're helping them in terms of their

lack of understanding about the their

partner's anatomy?

>> Giving men a road map, being very

descriptive. You know, men, most

partners want their partners to be

happy. It's not, you know, there's the

selfish aspect of performance and

there's the sexual empathy component

where they care about their partner and

they want their partner to feel well.

Giving them a road map to sort of

explore around and find the anterior

branch and think about the wishbone

structures um is really exciting to

them. Um desire, spontaneous desire,

thinking through that is really exciting

for them. how they tap into that, how

they can curate that with your their

partner, thinking about their partner's

arousal. Um, and then sort of supporting

there's a communication component. I

think when we think about sexual

dysfunction, we tend to break it down

into a biocsychosocial model. Um, I like

to talk mostly about bio. I'm a clinical

physician. I'm a gynecologist. So I

think a lot about anatomy and

pathophysiology and neurotransmitters

and hormones, but there's a lot of other

people in this field that are helping

with the psychosocial sex therapists,

communication. There's a great book

called sex talks by Vanessa Marin, which

talks about how to communicate with your

partner. Um, clitorate is a great book

to think through different ways that you

can sort of improve your communication

about what pleasures you and how to

investigate that. There's really good

websites now. OMG yes.com is a website

that sort of talks about your anatomy

and how to find it and how to find your

pleasure spots. So there's a lot out

there. I'm not alone in this space by

any means, but I like to think about it

from a very sort of biologic physiologic

perspective.

>> You mentioned a moment ago, for example,

that a number of women are able to have

an orgasm during intercourse, but it

requires them using their own hand, for

example. Mhm.

>> Um, how much does a woman control her

ability to have an orgasm by the way she

positions her pelvis?

>> Female dependent and dependent upon your

own anatomy. So if you're, you know, so

in thinking about how far your

clitoreral hood is from your vaginal

opening, thinking about if you're a

lefty or a righty, understanding your

anatomy, exploring your anatomy, um, can

help you sort of figure this out and

talk to your partner about it. So yes,

there there is a good amount of control

that women can have over this, but the

first step is understanding their own

anatomy. Is it a myth that if a woman

uses a vibrator regularly on her own, it

makes it harder for her to have an

orgasm with her male partner or or

unless she becomes dependent on using it

as well?

>> It is a myth. Um there are um in the

sense that there is data on either side.

Um, and so there is some data that talks

about if you sort of acclimate to sexual

practices that you cannot bring into a

partnered model, then it may be harder

to have orgasms in a partnered

situation. But if you are comfortable

using whatever technique you find upon

your own time and you can bring that

into your relationship, then you're more

likely to have orgasms. And so thinking

about whatever it is that you're doing

and however it is that you're doing it,

if you can sort of inject that into your

part life with your partner, you are

more likely to have orgasms. There is

really good data that sort of uh orgasms

beget orgasms. Meaning like the more

orgasms you have, the easier it is to

have an orgasm in terms of training the

system sort of learning learn you know

your body's response to to stimuli can

be trained. Your body's response to

things can be trained. Um, and I think

from a um, going back to sort of how we

how we could use this from a desire

perspective, there is good data that sex

begets sex, meaning the more sex that

you have, um, the more sex that you

want. And so I talk to my patients about

scheduled sex as a way to sort of work

on your desire. And

most of my patients when I bring up

scheduled sex are like, "Oh my god,

another thing I have to do." Like, uh,

what a hassle. And I sort of I I point

out um the fact that you you've always

scheduled sex, right? Like when you met

your partner and your partner said,

"What are you doing Friday?" He he was

scheduling sex with you. And when you

said, "Sushi sounds good." And you

shaved your armpits and put on a nice

t-shirt, you you were planning for sex.

So you are prioritizing your sex life in

a way. And so uh scheduling sex is a

great technique that we use. Um how that

sort of rolls out is depends on the

patient and what frequency they're going

for. But I have my patients do uh what I

call [ __ ] it February where I

essentially have my patients having sex,

scheduling sex two to three times a week

for the month of February. It's a

romantic month. It's the shortest month

of the year. Um, and this sort of takes

pressure off of patients wondering, you

know, the person who's been the

initiator sort of gets to relax and not

have to worry about rejection. And the

person who has been less interested

knows that they're sort of working

through an arousal pathway. They're

working on SP responsive desire. Um, and

scheduling just means that you'll show

up. You don't have to have sex, but you

just show up and you try it. Um and

there's great data that sort of after a

month women will sort of have that

maintenance of uh you know their

increased desire and they can sort of

ride on that for a couple of months.

>> You mentioned earlier discordance as an

issue, discordance of desire. Um how

often is the discordance

um in one direction versus the other? So

how often is the discordance that the

male wants more than the female and vice

versa?

>> I wish I had a specific number for you.

Um, we can probably look that up and put

that in the notes, but anecdotally, I'll

say it is most often um, the male has a

higher desire than the female.

>> Does it say anything about the couple if

it's the reverse or is it something

>> I anecdotally as well have I I have the

reverse as well. And there's so much

that goes into this in terms of like,

you know, the partner's health status

and chronic diseases and and, you know,

stressors at work. So, there's a lot to

sort of think through and it can happen

both. It it can go both ways, but by far

and large, it is predominantly the male

with the stronger sexual desire.

>> And so, on the topic of sexual desire,

what are the, you know, because this

podcast is called the drive and we're

talking about cars. Uh, what are what's

the throttle and what's the brake pedal

on sexual desire for men and for women?

And I assume it's different.

>> I would assume it's different, too. I

never talk about men because I'm not an

expert in men's sex life. So, I'm going

to I'll I'll recuse that to to the next

guest. Um, but when we think about women

and we think about accelerators and

breaks, it's a common framework that we

use. Um, from a social behavioral

perspective, like, you know, what helps

you feel relaxed and what turns you off.

Um, but from a pathophysiologic

perspective, we think about

neurotransmitters. And so, accelerators

from a neurotransmitter perspective

would be things like estrogen and

testosterone, nitric oxide, dopamine,

and oxytocin. And those sort of five

neurotransmitters are in a complex

interplay to sort of tell our brain and

our body through a variety of different

pathways. I'd like to participate in

intercourse. Estrogen is very

interesting um because although we know,

you know, there's different types of

estrogen receptors throughout the body,

but when it comes to sort of sex drive,

we think about alpha receptors um which

stimulates sex drive and beta receptors

which decreases anxiety and inhibition.

But it's not as clear-cut when we

replace estrogen. It's not a slam dunk

that you know you cannot make the

connection then that oh so if I replace

estrogen as it's dropping I fixed my sex

drive all is well. Testosterone has a

little bit more of a direct link to

that. So when we think about for example

the post-menopausal female and I'll use

the term menopause hormone therapy over

hormone replacement therapy. Um and I

would be so excited if you switched your

nomenclature as well. Um, but I think

when we think about post-menopausal

women, we think about menopause hormone

therapy replacing estrogen. Um, we

sometimes do see an improvement in sex

drive. Um, but that's usually through an

indirect pathway. You're sleeping

better, you have more energy, like

you're not having as many hot flashes.

So, we'll see sort of an indirect

improvement in sex drive. Testosterone

is, you know, wellstudied for hypoactive

sexual desire disorder or a problem

with, you know, I wouldn't say, a

decrease in your sex drive. um to to

meet that diagnosis, you have to have a

low sex drive for more than six months

and you have to care. Not your partner

cares, but you have to care. And if you

meet that diagnosis, testosterone is

very well studied um in terms of its

benefits on your sex drive.

>> What is your preferred method for

administering testosterone to women?

>> I prefer a cream. Um I you know I think

prescribing test I so I do also

prescribe testim um which is an oil um

and that's where I will sort of like get

realable packets. I'll put it into a

empty syringe and that syringe um uh the

kind that we give our children Tylenol

with not an actual uh needle syringe but

um and so and then you can administer.5

cc's and rub it on the inner thigh is my

favorite place to do it. I do a lot of

um compounding cream. I use Koshlin

pharmacy. They have a pretty standard

like well-mixed formula and I'll sort of

use um I'll prescribe a testosterone

cream where the patient will use a pump

a day when they get out of the shower.

They'll let it dry for 20 minutes and

then they can put on their get sort of

get dressed.

>> Do you think the oil is more efficacious

and consistent in its absorption than

the cream?

>> I don't um I find sort of when and and I

do try I do follow labs um when

prescribing testosterone. So anecdotally

and from a lab perspective I don't find

a difference. I'm interested in what you

say. I sort of go based up based more on

patient preference. If they want an FDA

approved product, although it's not FDA

approved for women,

>> then we'll go ahead and use the testim.

If they don't, I much prefer to just

compound it. It's it's cleaner, it's

less messy, it's easier to dose. Um

there's so many um dosing issues with

the oil in terms of how we dispense it

when it's not dispens, you know,

supposed to be dispensed for women that

I much prefer the cream. How about you?

uh we use a cream more typically.

>> Yeah, I don't use intraasal. Um I do use

intravaginal. So I will use um but sort

of in the form of DHEA. Um I use a lot

of intraosa. Um intraosa or prosterone

is sort of a metabolite that can

ultimately you know come down the

testosterone estrogen pathway. I will

use that. Um but uh in terms of that's

for pain of the vagina but when it comes

to sort of sex drive and desire to

administer testosterone mostly cream. Do

you target a um a level for total

testosterone or free testosterone or are

you just basically saying I want to get

it above a certain floor and then

symptoms determine where we end up?

>> I want to get it above 20 in terms of

total testosterone. Well, that's a low

floor.

>> It's very very low. Um and then I use

symptoms. Um and so then I use so so for

example um so 20 to 80 would be you know

the range at which I'm interested. Um

but I'm I predominantly use symptoms. um

there the guidelines in terms of how to

titrate it are not clear and I you know

anecdotally I'll have patients at 80 who

have no benefit to their sex drive. I

have 20 who see a great benefit. So I

want to see like you know some sort of

mo modest improvement in their

testosterone and then interview see how

they're doing. And given how much

variability there is in men with

androgen receptor density, we I I think

we have a pretty clear sense that in men

levels don't tell you much unless you're

below, you know, 350, 400. You know, if

you're below that level, you're really

going to be hypogonatal. Um, but men can

be replete at 600 and other men might

not be replete till they're at a,000.

And again, it just comes down to AR

density. Do do you have any sense of how

that works in women

>> other than it's incredibly complicated

as you alluded to, but more so in women

because most women who are on

testosterone are also on estrogen and we

know that estrogen increases your sex

hormone binding globulin quite

significantly. Sex hormone binding

gabbulin being that protein that sort of

runs around and gobbles up free

androgens or testosterone. And so, you

know, because I'm prescribing estrogen

and um that we know progesterines

actually have the ability to to blunt or

mitigate that increase in the sex

hormone binding globulin, the more

androgenic the progesterine, the more

mitigating effect on that increase in

sex hormone binding globulin. And so,

this is where this is my true passion in

sort of thinking about hormones and

contraceptive and menopause hormone

therapy and sort of tinkering with

hormones because some of what you do

will help the sex drive. some of what

you do will hurt, but the addition of

the two variables of estrogen and

progesterine make this incredibly more

challenging.

>> As you know, we talked about this at

length with with Rachel Rubin, but I

think it's always worth rehashing. How

how do you like to initiate um estrogen,

progesterone, and testosterone use in a

pmenopausal woman who is um obviously

one of the most difficult to treat

because she still has waxing and waning

natural levels of all of those hormones.

but during her naters is is typically

pretty um debilitated by the symptoms.

So, how what what is your what is your

playbook on that which is obviously

pretty challenging.

>> This is when you'll see me get very

animated. I I love this topic because

it's so different. It's so different for

each woman in terms of how she responds.

The first question that I try to answer

in my interview with my permenopausal

patients is do you like ovulating or

not? And that's the sort of first branch

point at which I sort of decide how I'm

going to approach this patient. Um,

>> let's just stop on that question for a

second. I've never really thought of

that question, obviously being someone

who's never ovulated, but

>> tell me why that question matters and

why would a woman know the answer to

that question at the risk of sounding

naive.

>> So, I'm going to answer this from first

a sexual health perspective and then a

general health perspect. Some people

when their sex drive is higher around

ovulation, they love it. They like the

benefit that ovulation gives to their

sex drive. There are times in the month

when they have a great sex drive. They

ovulate and they feel good. Similarly,

um the first half of your cycle when

estrogen is climbing right before

ovulation is a per is a high performance

part of your cycle. And so these women

who like to cycle feel good the per the

first part of their cycle. They feel

great right before ovulation. Um there

are a lot of biometrics that are peak

right before ovulation. Um your memory

is stronger, your energy is stronger. Um

I have a few Olympic athletes in my

practice and we will figure out when

their events are and we will try to

figure out their ovulation so that they

are competing in the first 10 to around

day 9 10 11 12 um to 15 of their cycle

because right before ovulation is where

they can lift the heaviest, they can run

the fastest. I'd love for you to do a

study on V2 max throughout the cycle,

but I it's really interesting when you

look at the the metrics that we care

about. Many of them are peak. So,

>> but sorry, just to be clear, at that

moment in time, her estrogen is pretty

much at her highest, progesterone is

very low, testosterone is high.

>> Correct.

>> So, does that mean progesterone is a

performance inhibiting hormone or does

it mean that estrogen because obviously

testosterone is a performance-enhancing

hormone. Does it really mean estrogen is

performance-enhancing, progesterone is

performance inhibiting? Because in the

in the ludial phase, you would also see

high estrogen, but you now have high

progesterone

>> and not as high estrogen, but you're

correct. Um, I think to to make this at

the risk of boring um anyone listening

to get a little more academic about it,

you're really talking about a pro

progester is sort of which is a there's

estrogen and there's progesterrogen.

Within progesterrogen, there's

progesterines and there's progesterone.

Now natural progesterone we know which

is that's what's in your body is

progesterone. Yes it is a sort of rest

and digest a low energy phase a

preparation in case helps with sleep.

>> Helps with sleep. Um but in terms of the

progesterine

>> prepares for implantation prepares for

pregnancy. Yeah.

>> Exactly. In terms of the proestines

which are a synthetic class of

progesterrogens we then think about what

is the family that this was derived from

and the side effects can be very very

very different. And I think about that

in terms of what pills I will prescribe

my patients. But to bring it back to the

question, um I essentially through

interview and this is where the patient

can really advocate for herself, you

know. So for patients who are listening,

we you're we care like doctors, we we've

worked our butts off to get here. We

deeply care about helping you. All

doctors do. Um, but you sort of coming

in with great symptom tracking and

timelines and relations to bleeds and

things like that can really help us

understand through interview whether

you're someone who feels great because

of ovulating or whether you're someone

who, you know, really suffers from PMS,

premenstrual syndrome, has it turned

into premenstrual dysphoric disorder

where it's PMS but now it's impacting

your life. There's so many reasons by

which you would say, I actually feel

terrible cycling. I would prefer not to,

but that's the first branch point when I

have a permenopausal woman.

>> And just give me the divide there,

Sally. What percentage of women who are,

let's just call it, 44 years old, 45

years old, will respond to that first

question as, "Yep, I really enjoy

ovulating. Let's keep it up versus let's

make this go away."

>> I would say about 70% of my patients, 70

to 80% of my patients prefer not to

ovulate. Okay,

>> this is the 45-year-old who's like, you

know, I used to be really short-tempered

with my kids the day before my periods

and now I'm just, you know, it's the

whole week before. I'm really

short-tempered. Um, so, you know, I have

all of the symptoms of low estrogen, hot

flashes, vaginal dryness. I have all

these hypoestrogenic symptoms, but I

also have, you know, pmenopause is, you

know, your brain is yelling at your

ovaries to please do one last ovulation,

listen up. So you have this sort of

hyper stimulation of signaling um a

hyper response of FSH follical

stimulating hormone um so much so that

you can get you know a loop event which

is a ludial out of phase event where

essentially you ovulate twice your FSH

is so high it's so busy yelling at your

ovaries that your ovaries are like I

heard you and I heard you again and they

essentially double ovulate and that's

that story where you'll have you know a

long cycle and then a short cycle and

then a long cycle. So, these are all

clues that you don't like to ovulate.

And so, if you do like to ovulate, let's

go down that sort of less lesser

travels.

>> By the way, you're the first person

besides me who I've heard use the

yelling analogy. I'll never forget 10

years ago, I was sitting down with a

male patient and he came in and he had a

pretty high testosterone. It was I mean,

not very high, but it was probably like

7 or 800. Um, which for his age was

actually pretty high. and his FSH and

his LH were 2x normal and he wasn't

taking, you know, anything. And I was

like, "This is really interesting." And

he's like, "Why?" And I sort of drew him

a picture and I said, "Basically, your

pituitary gland is yelling. It's

screaming at your nuts and they're

really responding." And like I forgot

about the statement, right? And like a

six months later, a year later, two

years later, he keep coming back with

that. At some point, I started taking

care of one of his friends. His friends

told me about it. They're like, "He's

really been bragging about this." And so

anyway, I just thought, you know, I'm

sure women do not go and brag to their

other friends that their pituitary

glands are screaming at their ovaries,

but that's a guy thing. A guy would brag

about that.

>> I would agree with that. What what women

do do is, you know, they're they're

walking around the block with their

protein shakes. They're, you know, doing

their thing. And you have one

46-year-old average age of pmenopause

being 46. You have one 46-year-old

saying, "Gosh, I I feel so great. I'm on

a birth control pill and I just feel so

great." And the other 46-year-old's

like, "Me, too. I'm on menopause hormone

therapy. I just feel so great." And then

they look at each other like, "Wait, why

are you on that? Wait, why did you why

are you on that?" And the heart of this

for me is who likes to ovulate and who

doesn't? And from a sexual health

perspective, understanding is your sex

drive and all the other things that make

you happy and feel good, which

ultimately go into your sex drive. Do

you want to ovulate? And if you do want

to ovulate, then we can think about, you

know, do you need contraception, right?

So, how can we sort of Yeah. And sorry,

just go down that branch point again

because you just you just made a

distinction that I

>> I don't know that every listener will

understand. You just talked about oral

contraceptives which are hormones and

then menopausal therapy which is

hormones. Can you explain why that

branch point is different for in

response to your question?

>> Yeah. So um menopause hormone therapy

the dosages do not suppress the

gonadropen pathway. And so when you are

on menopause hormone therapy you still

ovulate. If you're going to ovulate you

still

>> you're going to still ovulate through

it.

>> Yeah. Whereas um contraception

um many forms of contraception suppress

ovulation but not all forms. To be clear

when talking about contraception and how

it affects your sex drive, I just want

to sort of you know we talk about

ovulation and how women's sex drive can

be ovulation dependent.

Remember though that we've looked at how

suppressing ovulation impacts your sex

drive. And the data shows they've great

um meta analysis of 32 trials and it

looked at over 14,000 women and it said

that 20

and it said that 20% of women who

suppressed ovulation uh still had an

increase in their sex drive. 65% had no

change in their sex drive and 15% had a

decrease in their sex drive. So, I don't

want you to think that by choosing some

form of contraception that suppresses

ovulation, you know, will absolutely

have an impact on your sex drive. It's

so multiffactorial and safety from

pregnancy can be so sort of uh

reassuring for patients that that's, you

know, definitely not the case. Um, and

when we think about how hormone pills

can impact um, your sex drive, we think

about sort of the two-fold suppression

of the hypothalamic pituitary access in

terms of suppressing your hormones

downstream and your therefore ovulation

um, but also going to your ovaries and

shutting them down which then decreases

their production of testosterone. So

even though yes we have you know

biologic plausibility for how

contraception impacts your sex drive

there's so much going into this from a

biocschosocial perspective that we don't

see the you know equal number of changes

in terms of how it actually impacts your

sex drive and so once we sort of

identify okay you do not want to ovulate

then we can sort of march down okay do

we want to use do you need contraception

do we need to do contraception but that

continues to allow you to ovulate things

like a paragard IUD D spermicides, you

know, um there's uh vaginal pH

modifiers. There's many ways that we can

provide contraception uh without

impacting your ovulation. Um or if

contraception is not an issue and you

like to ovulate, then we go down the

menopause hormone therapy route. If you

said that 70% of women would be fine

without ovulating anymore, does that

imply that 70% of permenopausal women

would be better off on oral

contraceptives than on estradi and

progesterone?

>> My patients and

yes, in my patient panel, they are

happier on that. What's what's really

interesting is um

>> I want to talk about so when we think

about menopause hormone therapy, we're

thinking about 17 beta estradile, which

is this estrogen. It's an E2 and it's uh

the predominant estrogen when we're in

our reproductive years. And there's so

many benefits to this estrogen, right?

Um there are some new birth control

pills on the market that have this 17

beta estradile. So it's an fascinating

mix where you're suppressing ovulation,

you have contraception, but you're

potentially still getting the health

benefits of being on a 17 beta estradi

or an estradiate which is metabolized

into 17 beta estradile. And so for my

permenopausal patients, once we

establish, okay, do you want to ovulate?

Yes or no. Do you need contraception?

Yes or no. Then we can sort of think

through how we pick a pill. Because that

would be my concern with an oral

contraceptive as a bridge through

menopause, which is they're missing out

on real estrogen and progesterone. And I

think we have pretty good evidence that

the benefits you acrew later in life,

especially with respect to bone density,

but probably with respect to other

metrics of health, are heavily dependent

on getting real 17 beta estradiol and

real progesterone right away. never

having an interruption in those

hormones. So if if if that is correct.

Yeah. If that if if what we believe on

that front is correct, then it means any

woman who's going to go down the oral

contraceptive route would be best

receiving that oral contraception in the

form of what you just described, which

is a real uh 17 beta. And I guess my

next question, I I'm worried I know the

answer to this question, but I'm going

to ask it anyway. Um, what is the cost

of that type of oral contraceptive and

how often are insurance companies

covering that?

>> Rarely covering it. So, so to sort of

>> And the out-of- pocket monthly cost on

that pill would be how much?

>> 100ish 100ish a month.

>> So, it's a huge expensive.

>> Yeah. It's incredibly uh prohibitive.

So, when you, you know, if you were to

think about, okay, so now I'm

permenopausal and I don't want to

ovulate. Um, I want to be on a birth

control pill. The first question is, do

I want to be on estrogen? You and I are

sort of alluding to the fact like yes I

want to be on estrogen but a certain

kind of estrogen remember some people

are not candidates for estrogen right

migraines with ora blood clot family

history so um then but we still want to

suppress ovulation the newest

progesterone on the market is something

called drosperinone drossperone the pill

is called slind it suppresses ovulation

in about 98% of women whereas previous

progesterone only pills suppressed

ovulation 50 to 70% of the time so

you're getting a huge mood benefit

um for these women who cannot take

estrogen but really don't want to feel

the ups and downs of pmenopause cycling

which can be wild um dresperone being a

derivative of spirolactone there's a

diuretic component to it and so it's a

really well tolerated really exciting I

hope I can convey how excited I am about

this progesterine because having

drosperinone means that we can mitigate

some of the other side effects and so

>> such as water retention

>> water retention and so then Okay, so now

we've decided, all right, I if I don't

want estrogen, I'll use slind, this

dresperinone only but ovulation

suppressant medication. What if I do

want estrogen? Um, then the branch point

is, do I want something synthetic, said

very few people ever, or do I want

something more natural, said both of us.

Um, the people who do end up on a

synthetic estrogen are it's um it costs

it's cheap. Your insurance covers it.

Um, uh, it's available at allies. So

there's sort of an access issue here

that we would be sort of remiss to

ignore. Um I still have favorite pills

and uh within that category, I still um

have pills that I like. And

historically, if you interview patients,

they may be able to tell you, oh, I did

well on this, you know, synthetic

estrogen. So as we sort of get into the

later 40s, I care more in terms of

getting them back on a more natural

estrogen for the reasons you mentioned

in terms of bone prevention. talking to

a 28-year-old woman who just needs birth

control. You don't have a concern with

putting her on a synthetic estrogen.

>> I I don't and I still have favorites.

So, I still, you know, Loestrin.

>> I was just about to say that's my

favorite.

>> Yeah. So, I use Lolo estrin a lot. Um

Lolo estrin is norone progesterine. The

reason why I like Norah syndrome is it's

a little bit more androgenic. The more

androgenic the progesterine, the way the

it has the ability to blunt or mitigate

the increase in sex hormone binding

globbulin. Again, I'm talking about

pills from a sexual health perspective.

There's lots of other ways you could

view this, but today this is my angle.

And so, when you think about a super

lowdose ethanol estradi, low side

effects, um, plus a, you know, slightly

more androgenic progesterine, you then

can have a, you know, blunting of the

increase in sex hormone binding

globulin. less likely to gobble up all

those extra androgens and patients

tolerate it really well. Side effects

are there's more bleeding because of the

low ethanol estradi. So sometimes I'll

go up to a less um which is a 20

microgram ethanol estradiol and this has

a levenogestral progesterine to it. And

this progesterine is similarly a little

bit more androgenic less likely to

impact your sex hormone binding

globulin. And then my last two very

popular Yas and Yasmin. The reason why

those are so popular is the progesterine

in them is drosperinone. And so it has

that ability to to to not diuretic.

>> Exactly. It acts as a diuretic. Um when

we think about ethanol estradile and I

if I could just sort of step out of

professionalism for a moment and ask my

father-in-law to tune in because he's a

nephrologist and he would be so excited

to hear that I'm going to talk about

angotensinogen which is um in the

kidneys estrogen goes ethanol estradiol

goes to the kidneys um and some 17 beta

estradile goes to the kidneys and causes

sodium retention water retention. So

when we think about estrogen and how it

impacts our bodies, our PMS, our breasts

feeling heavy and painful, bloating,

slight weight gain, this is from this is

estrogen effects and drosperone being a

derivative of spironolactone can have a

mitigating or a diuretic uh blunting

effect on that water retention. Um Dave,

if you could tune out now because I

might say orgasm soon. Um, but anyways,

uh, using this sort of counteracting

principle in these newer medications can

help me pick a really good synthetic

form of contraception. Now, if we're

going to go to the natural form, um, one

of the there's a few combinations that

I'm using now that my patients are

tolerating really well. Um, the first is

to go back to that progesterone,

progesterine only pill, progesterine

only pill, which is slend drosperanone,

and adding a 17 beta estradiol patch to

it. So you're essentially taking an

ovulation suppressive component of

contraception but adding in menopause

hormone therapy estrogen and that's

where the benefits are. You get the bone

protection, you get the So for my

patients who are on contraceptive

>> but you're saying the sorry to interrupt

you the progesterine alone will help

with suppression of ovulation

such that you can use physiologic 17

beta estradiol.

>> Correct.

>> That's super interesting. I I'm ashamed

to admit I didn't know that. So it's a

great this is a great um sort of uh in

between step because you can provide

contraception you can provide your

spirone which is a diuretic which 17

beta estradile does have

>> you know some sort of uh water retention

components to it but the downsides to it

as the although these sort of work very

well throughout the body they at the

level of the endometrium or the lining

inside the uterus is um you have a

little bit more breakthrough bleeding

because the 17 beta estradiol does not

stabilize the endometrium as much. So,

one of the side effects in limiting

reasons for which I won't my patients

won't be happy on this is if they're

having breakthrough bleeding. Um, so

when there's other options that are

better at that. So, a newer the sort of

two medications that I I want to make

sure you know about and I have no

disclosures but I'd love to have some um

is is uh the next medication that we

think about is Nexelis and Nextlus is

drosperinone um which is the

sperolactone derivative the l the

diuretic um with estetrol or E4. It's a

natural estrogen. It's typically

produced by the fetal liver. Um, but

this has a longer halflife than 17 beta

estradile. So, you get less breakthrough

bleeding, less spotting. Um, we don't

know. We think natural estrogens. You

must get bone protection and bone

benefit. We don't know yet. It's

currently being studied.

>> It it it's only made by the fetal liver.

Correct. So, that you have none of this

in your body right now.

>> Hopefully not.

>> Hopefully. Yeah. Unless you're taking

this.

>> Hopefully not. Yeah. And

what do we understand about and this we

might have to cut this out of the

podcast because it is so freaking nerdy

at this point but we understand how E1,

E2 and E3 estrone estradile estriol we

understand I mean if we want to we can

understand exactly how they move between

each other and

>> um

>> do we understand how E4 fits into that

pathway? Does E4 have any conversion

back to E2

>> or is it acting as an independent agent?

>> We don't we don't we don't totally know.

We think it's independent. Um but what's

a really something we do know about E4

is that it does not activate the

angotensinogen pathway. So

>> so you don't get these

>> so you don't get the water you don't get

the bloating. So you have that plus

drosperone and patients feel really

good. Remember drosperone is so good for

bloating.

>> We don't know that this has I mean until

we know if this is going to be

protective of bones and all these other

things. Wouldn't there be a risk that

we're solving one problem without

addressing the jugular problem?

>> Yes, currently being studied, but it is

a um the benefits of drosperinone less

spotting or breakthrough bleeding than

the drosperone plus menopause hormone

therapy level estrogen. Um,

but I think by you asking that question

and sort of the the dedication to making

sure that we're on a studied 17 beta

ethanol estradiol, the newest medication

on the market is called Natasia

and Natasia is a progesterine um with

estradiol valerate which essentially is

17 beta ethanol estradile and this is a

huge sort of hugely important uh

contraceptive option for a few reasons.

The first is it's the only contraceptive

pill that's been approved by the FDA to

treat heavy menstrual bleeding. And this

is a huge issue in pmenopause um and

contributes greatly to you know sex

drive and desire.

>> But this is once you've ruled out

fibroids and things that otherwise can't

be treat like that are not going to be

>> this is sort of like um you know I said

that I wanted to stay in sort of the

normal pathology part for this for this

podcast. um a ludial out of phase event

when you're double ovulating and having

heavy bleeding of perry menopause that

still to me falls in the in the in the

realm of normal. Um so nasia is great

because it's great for um heavy

menstrual bleeding but the estradile

valerate or the 17 beta estradile you

get the hot flash benefit the bone

benefit you get the benefits of

menopause hormone therapy um with

something that can also help bleeding

and prevent pregnancy. And just to close

the loop on progesterone,

um if you're using progester micronized

progesterone, even at 200 milligrams,

which would probably be the upper limit

of what we would use, you're that's not

enough to stimulate uh to suppress

ovulation. Obviously,

>> 300 is

>> 300 plus is what you would need to to to

sort of um predictably reliably.

>> But of course, at three, most women

can't tolerate that. sedating, you know,

and additionally, you know, not to be

left out is menopause hormone therapy

plus an IUD, right? Or menopause hormone

therapy plus the salpine jacktomy,

removal of the tubes. There's other ways

to get at this, but I think that's why I

really start at the branch point. Those

those points do not um block ovulation.

So, that's why to me, I really care how

you feel in relation to ovulation. And

that's the branch point in how I decide

how to treat my patients. So, a lot of

what we just talked about probably went

over the heads of a lot of people, which

is understandable. It is pretty

complicated stuff. Um,

I want to kind of bring this back to to

a listener, right? To me, the takeaway

is if you're a woman, um, you've got to

show up with a point of view on what

you're trying to optimize around. You

have to show up on a you show up with a

point of view around preferences. Um,

and this one around do I like ovulating

or not is important. So, that's

something that regardless of how young a

woman is listening to this, and you

know, truth be told, I don't think our

audience skews very young, but I'm sure

there is a 25-year-old out there

listening. This is something she can be

paying attention to right now, right?

She's 20 years away from having to deal

with what we're talking about, but she

can still be pretty receptive to the

idea of how do I feel during my cycle.

>> That would be my greatest takeaway. and

to sort of and to and to make you aware

that that changes um that the the way in

which we feel in the second part of our

cycle um as our estrogen declines as we

age can become more and more dramatic.

So it's a very important question to me

for everyone and a very very important

question for me for my permenopausal

patients.

>> And how much does that change based on

uh children and and um and the number of

children a woman has or any other factor

like that? I I would feel a little

theoretical going into that. I don't

think we have great data. There's some,

you know, some some some studies talking

about the later um in your, you know,

the later you have your last child, the

earlier you'll go into pmenopause.

um the way that I think about um

hormones and and what happens from a uh

I think one thing I want to go back to

from a neurotransmitter perspective is

you asked me about the accelerators and

we launched into a discussion about

hormones but we didn't talk about the

brakes um and the brakes are uh

serotonin um so we know about how SSRIs

um can impact our sex drive and what to

you know we can think about what to do

about that but prolactin um is a break.

And it's really interesting because when

in our lives is prolactin highed,

breastfeeding, postpartum and so women

can find this very validating. But from

a biologic perspective, we know that

pregnancies spaced 18 months apart.

That's the ACOG or American College of

Obetrics and Gynecology, they recommend

18 months between pregnancies because

that second pregnancy will be healthier,

the baby will be bigger, it it's more

likely to make it to term. So, we know

that spacing pregnancies is healthy. And

so, having a high prolactin postpartum

and keeping you from being interested in

sexual intercourse is your body's

natural way of spacing out pregnancies

for the better.

>> While we're on the topic of evolution,

there's there's something I've I've

always wondered um that seems a bit at

odds with pure a pure natural selection.

And this is going to expose how naive my

thinking might be. So, it's not a

surprise that men would have a high sex

drive for as long as they are capable of

reproducing, which is seemingly

indefinitely, right? Um, but you you

could make an argument maybe

theoretically that women's sex drive

should decline after a certain age, call

it 30 or is when when evolutionarily

their probability of producing healthy

offspring goes down. But I don't think

we believe that to be true at all. I

don't think we see that women's sex

drive goes down as they age, which sort

of flies in the face of maybe at least

one naive interpretation of what natural

selection might interpret. So, is there

is there a smarter explanation for why a

woman's sex drive goes up or or it

doesn't go down? Maybe to phrase it more

accurately,

>> there are many explanations. Um uh you

know, this is hard to study. um

potentially the most popular one um

which the European Society of Sexual

Medicine gives like a grade two level B

rating. So not super high rating meaning

like case control studies.

>> No, this is theoretical but theoretical

if you if we can sort of tangent on the

theory for a little bit. There's

something called women's dual sexuality

>> and it basically talks about women's

motivation to participate in intercourse

being different at different parts of

the cycle. Meaning midcycle when you are

able to get pregnant, you are fertile.

You are more likely to participate or to

want to participate in intercourse for

purposes of reproduction. And the mates

that you are more likely to select

during that time will have features of

genetic dominance such as a very

symmetric face, more masculine features.

We talk about the hystocompatibility

complex and there's dissimilarity that

we look for at this time because we know

that mixing of heat is is better than

not. And then there's other times of the

cycle when you're interested in

participating in intercourse and you're

seeking out things such as partnership,

shelter, companionship, protection. And

so talking about this

>> and you're not optimizing around

>> and you're not and and you there you end

up with like a less attractive or less

symmetric or less masculine partner. Um

but your partner may have like better

communication skills, the ability to

provide better shelter, protection. Um

it's very interesting. People take this

and run with it online and they talk

about, you know, in your 20s, what form

of contraception should you be on when

choosing a mate? This goes back to that

question of do you want to ovulate or

not? because um you know there's so much

this is not an an anti- you know

ovulation anti-contraception discussion.

Um your sex drive is so multiffactorial

and being protected from from pregnancy

is you know for many can be such a

positive contributor to their sex life.

If you believe in this evolutionary

hypothesis and if you believe that you

would rather pick your future mate when

you're still ovulating versus being on

something like a contraceptive pill that

blocks ovulation, um there is some data

to show that you may pick a different

partnership. The the discussion section

is um you may want to pick a partner

that's has a less symmetric face but is

more likely to have a partnership and

communication skills, but that's that's

I'll sort of excuse myself from from

that. you can decide for yourself on

>> that is super fascinating and and

honestly there's more to explore there

than than the than the simple and

obvious stuff I proposed. I want to go

now back to some of the other stuff that

we talked about um around desire. We

didn't touch on this, but this must be a

very important topic that you deal with,

which is how much do adverse sexual

experiences during um during the early

part of a woman's life negatively impact

her ability to have a healthy sexual

life later on. And again, we can I think

we could talk about this across the

entire spectrum, right? So, we could

take the most egregious example, which

would be sexual assault, uh rape, things

of that nature. But then we can also I

think uh fan this out into things which

is just like no you know the first time

I had sex it was awful. It was in a car

in the back seat with a guy that I

didn't really know that well and we were

both drunk and yeah I was consenting but

it was awful. So it's hard to imagine

that many women can't relate to that

type of experience. How does that play

forward?

>> I see it incredibly

often um in my patient panel. it is

unfortunately um you know if you're

listening to this and you have a history

of sexual trauma you are unfortunately

not at all alone um and there are things

we can do about it so yes it plays a

part and yes we should do things about

it so there are lots of different

approaches um you know I hope that

patients are in therapy and that they

have sort of the right support team

around them I want to bring up sex

therapists are a great sort of uh

contributor in this area and sort of

thinking about um how you how your

experiences are brought into the bedroom

and sort of um you know, how do we sort

of use a traumainformed approach um when

sort of talking about how to curate

arousal and bringing yourself to the

encounter when you're not quite ready?

Um, there are there's a there's uh a

sensate focus exercise that is really

evidence-based for survivors of trauma,

but can also be very applicable to

patients who, for example, are listening

to this podcast and it's been a year or

it's been six months and they want to

sort of think about how to become

intimate again. And it's a it's a

four-step program

>> that can be done over a month, over four

months. You can sort of pick how long

each stage you want it to last. Um Dr.

Leia Melhouser who's done a ton of work

um in sexual health from a gynecologic

perspective um talks about this and it's

essentially um you know step one is to

you know let's say spend 20 minutes a

couple of times a week if you want it

the stage to last a week is to sort of

be intimate with your partner. No

touching of the breasts, no touching of

the genitals. Um step two would be okay

to touch breasts and genitals but orgasm

off the table. Um, step three would be

orgasms on the table, but no penetrative

sex. And step four is um penetrative

intercourse is allowed. And this is sort

of this is a evidence-based way in which

you can create a safe space to sort of

start to, you know, find yourself back

in your body. Um there is um a book

called uh the body keeps score which

talks about how to bring your sort of

mindfulness back into your body when you

are a you know trauma survivor. Um, and

Emily Nagowski talks a lot about it in

her book as well. Um, and then there's a

sort of potentially less traumatic but

still pain that can, you know, sort of

present itself in sexual encounters like

it just hurt. Like, you know, um, I see

this a lot in my cancer survivors.

>> I was just about to ask you about

cancer, by the way. So,

>> yeah. So, I see this a lot. Cancer I

often see sort of a twofold hit. there

is the sort of a psychosocial of I'm mad

at my body and I you know there's all

those sort of complex feelings and

there's the sort of like physiologic

aspect of you know chemotherapy

radiation and how that impacts pain and

lubrication of the vagina and you know

comfort of hormone use although you know

we really feel you know quite quite

confident that you know local estrogen

uh treatment of the vagina um is

completely safe um for almost all um

cancer survivors. Um Dr. Dr. Tammy Rowan

talks a lot about this um with um the

you know iswish and menopause society

sort of re you know encouraging not only

patients but also doctors to feel

comfortable prescribing local estrogen

in this patient population. Um physical

therapists pelvic floor physical

therapists can be incredibly helpful. Um

I think every woman you know if you're

sort of making a centinarian plan and

you're seeing a physical therapist to

keep your posture and your muscles

healthy health healthy I think you

should see a pelvic floor physical

therapist. They're, you know, great in

terms of increasing the tone of the

pelvic floor. We know that strength of

contraction can lead to better quality

orgasms. I often get emails like, "Oh, I

just had the best sex. Thanks for

sending me to the pelvic floor at this

physical therapist." Um, but it also is

good for hypertonicity where your pelvic

floor is too tight where you carry

stress and trauma and pain. Um,

you know, in terms of thinking about how

we take care of the vagina, I would like

to encourage you to think about taking

care of the vagina like you take care of

your face.

>> You you listened to my recent podcast.

>> I did. Um, and I would like to say, so,

you know, you're going to go out in the

sun, um, and you put on sunscreen. You

put sunscreen on your face. So, I if

you're going to have intercourse, you

should use lube. Um, that's just what we

>> even if a woman says, "I've never had

any difficulty with lubrication. I I I

don't have any discomfort with sex." You

still think a woman should be using

lubricant?

>> I do. The data shows less

microabbrasions. And also, what I really

>> and sorry, if you're not concerned with

sexually transmitted diseases, which is

what the WHO is concerned with, if

you're with one partner and only one

partner, are microabbrasions a problem?

>> They lead to pain. And once we get into

a pain signaling process, you can get

this is a common cause of what we call

vaginismas or a tightening of the pelvic

floor which then leads to more pain. Um

it is very possible and and and and you

should absolutely work at it. But

breaking a vaginismous cycle takes a lot

of work. And so part of this

recommendation that almost everyone

should use lube is this idea that we're

trying to avoid pain and we're trying to

young women. Yes. Um, this is one of my

favorite things to talk to young teens

about. Um, you know, when we think

about, uh, sexual education and we,

there's a great study looking at 1,200,

you know, high school students and ask

them about what we call sexual debut or

their first sexual encounter. And, um,

>> intercourse just

>> first sexual encounter

>> that includes kissing.

>> Uh, no. Uh, no, sexual encounter. Um,

uh,

>> what defines that?

>> I'm going to guess penetrative

intercourse based off of Yeah. Yeah. And

um 70% of boys gave responses related to

pleasure and 70% of girls gave responses

related to pain. And that's a big deal.

And so talking about foreplay and

lubrication, even for young women who

have an adequately lubricated vagina and

decreasing the likelihood that they'll

get into pain, that they'll clench up

the pelvic floor, it will then hurt

more. Breaking out of that cycle is

incredibly important to me. So yes, lube

if you're going to have sex. Um, going

back to the face, um, you likely are

putting moisturizer on your face

>> only recently.

>> Only recently. Um, so there's vaginal

moisturizers. So if you want to use your

vagina when you're older, using a

vaginal moisturizer, there's, um, good

ones on the market. There's Reie, um,

which is a hyaluronic acid suppository.

It lowers the pH of the vagina and

brings water molecules with it. Um,

there's Replen, which is a, um,

polycarbophil, um, suppository that also

recruits water molecules. you're

moisturizing your vagina. Um, and then

>> and sorry, just explain to me how this

is used. This is like part of your

nightly routine.

>> Yeah. Yeah. Put on your eye cream,

moisturize your vagina.

>> Morning.

>> Most people like evening because

>> then what if you're having sex after?

>> Um, so whether you're using a vaginal

moisturizer or whether you're using a

hormone, which will be the third part of

this uh facial analogy um

recommendation. Um, if you put it in and

you decide you want to have intercourse,

like please do. I wouldn't use it for

the purpose of it. It's sort of you're

playing the long game. So if you think

about sort of step three with your face,

you're using a vitamin C serum or a you

know DNA repair enzyme or an exosome or

whatever. That's sort of the long game

in terms of you know collagen and

overall sort of tone of the face. So

hormones would be the sort of

counterpart from a vaginal perspective

using using a yeah intravaginal topical

um local estrogen. of my patients who

are on menopause hormone therapy about

30 to 40% of them and that's consistent

with with the data are also on local

estrogen therapy. So just to be so clear

that um we treat local vaginal

conditions with local treatment for

women who don't respond from a vaginal

health perspective to systemic hormones.

>> All right. So let's let's recap that. So

the equivalent of sunscreen was

>> lubrication.

>> Lubrication. Um you said siliconebased.

>> I like it. So siliconebased um because

it is um needs it lasts longer. So

water-based lubricant doesn't last as

long. And so in order to make a

water-based lubricant work, they have to

add a lot of additives. you add

additives, you get hyperosmolar

um lubricants, which then if you go back

to high school chemistry means that

you're actually long game is water

molecules are going from the vagina into

the lubricant because of the osmolality.

>> So it's drying you out.

>> So it's drying you out in the long game.

So I like a silicone based lube.

>> Give us a couple brands.

>> I like Uber lube. The osmol Uber like

you're getting like what I took here.

Yeah. Like I took an Uber here. So I

like Uber lube. Um the osmolality is

600. Um, I like good, clean, love,

almost naked. Osmolality is about 280 to

300. The osmality of the vagina is 300.

Um, it's it's really quite shocking to

me when you go to, you know, a drugstore

and you sort of pick up, let's say,

Astroglide, the most, you know, sort of

popular. So, the Osmo of Astroglide is

8,000. Um, they have a gentler one

that's lower. Most people don't know

about that. Don't buy it. If you look at

KY, it's it's around 4 to 6,000. I mean,

it's crazy.

>> These things shouldn't be sold.

>> They should not be sold.

>> Um, but they are. And they smell good

and they

>> Why are they Why are they the most

ubiquitous lubes out there?

>> They taste good or they smell good or

they have a cool package or, you know,

it's essentially like, you know,

>> is do these uh lubes say the osmalerity

on the package?

>> If you look on the back, they should say

it,

>> right? So, you want to be basically in

the 280 to 300 range. 300. As close to

300 as you can.

>> Okay.

>> Yeah.

>> All right. So, that's great to know. So,

Uber Lube. What was the other one?

>> Good, Clean Love. Almost naked.

>> That's a long name. They can they might

want to shorten that.

>> Good clean love.

>> Okay. Good clean love. All right. And

then the sec. So, if that's your

sunscreen, um your moisturizer is

>> a revery or a replen. And these are

suppositories that you can put in the

vagina nightly.

>> And the suppository is providing what?

It is recruiting water molecules into

the cells and the revery is also

slightly lowering the pH of the vagina.

The lower the pH of the vagina or as you

know as close to the is is a natural

desirable outcome.

>> And how does a woman know if her

systemic hormone therapy

uh is insufficient and therefore she

requires topical as the third part of

this playbook. If you are going to

respond to systemic hormone therapy in

terms of

improvement of pain, disperunia we call

it

feels like sandpaper canal. There's a

sort of a rubbing raw feeling to the

vagina. You'll respond by about 6 to 8

weeks. So I tend to start my patients.

>> Got it. So give it a start. See if

things get better. If there's no change,

if you weren't having pain and nothing

gets better, Yeah.

>> you were probably fine. This strikes me

as a great example of something that a

male who's listening to this podcast

whose female partner is not could

actually bring home and talk about over

dinner. Like I'm honestly in the back of

my mind I'm look I mean half our

audience is men, half our audience is

women. So there's a there's a guy who's

listening to this episode whose partner

is not and he's I if I'm in his shoes

I'm thinking what am I what what what am

I bringing back to the table? And this

would be one of those things which is,

hey, let's have a discussion about these

three things, you know, and and um so

anyway, hopefully we'll link to examples

of all of these in the show notes. Um

what percentage of women are regularly

receiving oral sex?

>> I don't have that statistic. We'll have

to find that and look it up. I will say

that when you look at orgasm uh

frequency with any sort of intimate

encounter, it is one of the um highest

likelihood to be able to achieve orgasm

acts that a man and a woman can

participate in together. Um there's a

great book called She Comes First by Ian

Kerner that has diagrams and tips and

tricks and um talks about essentially

how how to do that. One of the best ways

if you sort of from a performance

perspective is to go back to the sort of

stages of orgasm that we talked about

the excitation plateau orgasm and

resolution. Um when you think about the

um plateau phase that's sort of the

hormone cascade that's happening in the

woman. There's two different ideas and

sort of that that are relevant here. The

first is um something called the

approach. And the approach is the

seconds or moments just prior to orgasm.

When surveyed, twothirds of women report

that whatever's happening when the

approach starts that it should just keep

happening exactly as it is. So no

increase in pressure, no increase

whatever you're doing, just keep doing

it. No change in temperature, pressure,

speed, depth, nothing. So understanding

that as sort of like a key component for

most women, but not all, can be

something that can sort of help you from

a performance perspective.

>> So So there's the the onus is on both

the woman and the man. The woman needs

to recognize she's there and have a cue

to her partner that says, "Don't change

a thing."

>> Yeah.

>> The guy needs to not try to be a hero

and needs to know when the when she taps

my head or whatever it is,

>> don't change a thing.

>> Yeah. Okay.

>> And that's a strategy to help women, you

know, sort of have more of a guaranteed

orgasm. And then the contrary is

something called edging, which is where

you do stop what you're doing. And

you're sort of like bring your partner

close to orgasm and then you stop what

you're doing and then you can bring your

partner close again and then you stop.

And this is for women to be able to

achieve more of an intense orgasm. This

edging technique. So, if if you were to

give a guy a few pieces of advice on how

to be more successful at helping his

partner achieve orgasm using oral sex

and penetration, what what what would be

your advice?

>> Lube. Get over it. It's evidence-based.

It's for friction. It has nothing to do

with how interested your partner is in

you. Um anatomical awareness. So,

understanding that there's two these two

wishbone nerve pieces. Um, enjoy being

massaged. Um, try to explore with your

finger two/irds of the way into the

vagina on the anterior or the front wall

where the G-spot is. Find that rugated

area. Um, lead up to the event. So, you

know, foreplay, what does that look like

for you as a couple? What does it look

like outside of the bedroom? Is it is it

you made dinner or you put the kids

down? What is your chore play? What

chores did you did as do as a part of

foreplay? um what nice text messages.

There's so much um contextual going on.

There's really funny um

research pieces that talk about, you

know, um uh people who are in the

military who are traveling around and

there's bombs everywhere and it's really

dangerous and men are still like ready

to have sex and women are feared for

their lives. So there's, you know,

there's women there's a lot goes into a

lot little bit more that or a lot more

that goes into women's uh sexuality that

I want you to be aware of. There's no

need to take this personal, but um I

hope today sort of understanding, you

know, arousal versus desire, responsive

desire, anatomically, thinking about not

just the tip of the clitoris, although

many men haven't even thought of that,

but in addition to the tip of the

clitoris, the wishbone structures that

go down, the anterior wall of the

vagina, thinking about, you know, what

phase of um orgasm your partner's in. Is

she in the excitement phase? Is she in

the plateau phase? um or is she sort of

in in the orgasm phase? And what does

that look like?

>> What about little details like for

example um if you're stimulating the

clitoris, is it just very individual

variation up and down, side to side,

around like

>> individual variation?

>> And is this something where a guy should

just ask a woman and say, "Hey, how do

you like this done?" Or is a woman put

off by a guy asking that?

>> In my dream world, these conversations

would take place. There's books that

walk you through how to have these

conversations. The sex talks book that I

mentioned by Vanessa Marin, she writes

it with her husband, so you get sort of

both perspectives. Um, but I think you

know that website omgs.com actually

teaches women how to find the different

techniques. So they go over, you know, a

hard stroke, a round stroke, a gentle

touch, an internal touch. They actually

teach women. And yeah, I have a dream

that women would, you know, go to this

website and learn for themselves how to

do it and talk to their partners about

it. Men can also go to the website. It's

a like a one-time flat fee website and

then you have access to all of their

content and it walks you through

different techniques. Um, so you can

actually learn and talk about with your

partner what she likes.

>> All right, let's pivot a little bit and

talk about um sort of the

pharmarmacology of arousal. We've talked

a little bit about it through a hormone

perspective and we've obviously talked

about how testosterone in particular,

but also estrogen and progesterone play

a role in um in the arousal of a woman.

But there are also drugs that are

specifically used to target this. What

what can you tell us about them? There

are a couple in particular that that I

know have come up on this podcast

previously. So um using that sort of

accelerator and break analogy many of

the medications will work on one or both

of those pathways. Um the two most

common medications and the only two that

are FDA approved for women are ADI which

is a pill and vile which is an

injection. They work along the MAOI

pathway on increasing norepinephrine and

dopamine and decreasing serotonin. So,

if you go back to those

neurotransmitters, thinking about

serotonin as a break, so they decrease

that um norepinephrine and dopamine um

to the reward center of the brain and

they increase those. Um I don't use them

a ton in practice. Um they are studied

for um they are not studied for

post-menopausal women. Um Addi is a

nightly pill. You take it for 6 weeks.

Well, you take it forever, but after it

takes about six weeks before you can see

benefit to it. Um, in the trial for

which it was FDA approved, it increased

your number of satisfying sexual

encounters by one. So, you went from

having like two to twoish satisfying

sexual encounters a month to threeish

satisfying sexual encounters. You can't

drink alcohol on it. Um

it can cause um nausea for some people.

Um it can interact with um

anti-depressants and mood stabilizing

drugs. It's not a contra indication but

can change the way in which they work. I

just don't use it very much. Why

>> why how much does this drug cost?

>> I don't know the answer to that.

>> Why do you think this drug was approved

with such limited efficacy?

>> It's statistically significant to go

from let's say twoish to three-ish

satisfying sexual encounters. But there

was a social movement at the time. There

was frustration about how easy it was

for Viagra to be approved. The data for

Viagra and men is much more clear and

easy to see. This is, you know, women's

sex drive is very complex and this, you

know, is potentially one angle at a

improving it. But from a

>> but it's a bit of a bad analogy. Viagra

is not really a drive drug. It's a

performance drug, right?

>> It's a performance drug drug that

ultimately can impact drive as well, I

think. Um

>> but it also impacts are there any data

that show that Viagra or Seialis or any

phosphodiestrase inhibitor improve

orgasm quality in women?

>> They've looked at Viagra a a a great

deal. Um the studies do not show for

women across a population level when

studied that it impacts drive or orgasm

quality except when looking at a

specific patient population. So when you

look at Viagra um the patients who had

an improvement in their quality of sex

be it dry or orgasm quality etc were

women um diabetics MS uh multiple

sclerosis spinal cord patients and

SSRIs. These are women who we think that

the vasoddilation of the nitric oxide

and the physiologic response that they

have to Viagra dosed at 25 to 50 you

know one one to two hours prior to

anticipated intercourse can be helpful.

Let's go back to Addie, uh, the pill.

Um, when I talk about, um, one

satisfying sexual encounter, you know,

improved per month, like remember that

that's compared to placebo. So, there is

still a great placebo benefit here. And

for many, that's, you know, exciting and

and fine to introduce uh into their

life. Um, Vissi is an injection. Um,

I'll you may you may get questions about

it from your patient panel because it's

similar to the peptide PT 141 U

melanotan. This sort of has the the um

the the the street uh name as the Barbie

drug because it works through the MCR4

or the melanocortic pathway. So you you

get tan and pretty happy and and horny

is what they say. So they they call it

the Barbie drug for that reason. There's

a significant amount of nausea. You

inject yourself um for the first two

hours. There's about 40% of women will

have nausea. I often prescribe Zopran,

an anti-nausea medicine when I prescribe

this drug. After twoish, three-ish

hours, the nausea can go away. And then

the drug lasts for up to six hours. You

can't use it more than twice a week. Um,

but this had slightly sort of similar

efficacy uh to Atti in terms of

improving your sex drive.

>> When when I hear that a drug causes that

much nausea and you can only use it

twice a week, I worry that it's doing

something unhelpful as a side effect

beyond what you just said. Do you have a

concern with long-term use of this drug?

We it has not been it's been out since

2019. We don't have particularly

long-term data on it. I have the same,

you know, questions. Um people

anecdotally do like it, but I do think

there's a great placebo effect going on

here.

>> Do you think one is better than the

other?

>> It's really hard for me to convince

patients to inject themselves with a

shot prior to, you know, an hour or so

prior to intercourse. It doesn't really

feel so

>> it's a preloaded

>> psychosoccially Yeah. sexy.

>> Um

Well, yeah. I guess it speaks to um

obviously the magnitude of the problem.

Have I don't suppose these drugs have

been compared headto-head to

testosterone?

>> I don't believe that they have. No,

>> I assume that it would be prudent to

make sure a woman's testosterone has

been pushed to the physiologic limits

before you would engage with any of

those drugs.

>> I just prefer testosterone, which to be

clear, testosterone is is is sort of

from a guideline perspective recommended

only in the post-menopausal woman. So,

if we're going to sort of stay in the

the you know, where is most of the data?

Why, you know, when do I ever use these

drugs? So, this is in the premenopausal

premenopausal

>> from an FDA perspective.

>> Exactly. So, if you're like, you know,

why even use these? This is studied for

premenopausal, testosterone is

post-menopausal. Um, but there's a lot

of sort of behavioral interventions

which I've already mentioned. Um, and

then, you know, sort of more off label

would be cannabis. Um there is some

pretty good data now that we have in

some states um you know legal THC um

that opens up for researchers to study

and investigate and there's really good

trials talking about cannabis and your

ability to have more satisfying sexual

encounters. Um uh but it is dose

dependent. So when we think about T when

we think about cannabis I'm probably

inverted.

>> It's inverted. Yeah. So it's

specifically THC. Um we around 1 to 2

milligrams is the recommended dose.

Anything higher for some can be sedating

to speak to your sort of inverse

relationship which adversely affects

your your sex sexual experience and

desire to participate. But around 1 to

two milligrams patients report that they

um have more satisfying orgasms or you

know have a hyper awareness of their

senses. Sex drive is higher. It's quite

significant in the data much more

significant than the medications they've

already talked about. and one to two

milligrams. Let me So is that through

any form edible inhaled? I I don't how

do you even I don't know enough about

how do you dose inhaled and and know

that you're getting

>> you know so first um you know if this is

an illegal substance where you live it

is not a recommendation if it is legal

there are safer ways to ingest THC.

Smoking vaping obviously have a great

impact on the lung was you know

incredibly worried about that. Um, one

of the best ways to to sort of dose

adjust is to to get uh name brand THC.

So, there are brands out there that have

um, you know, unregulated but some, you

know, but arguably quite standardized

dosing of gummies and you can get, you

know, 1 milligram or a 2 milligram or a

5 milligram.

>> And is 1 milligram um altering of senses

at all?

>> For most seems pretty low.

>> Yeah, it's pretty low for most people.

It's sort of a heightened uh uh sense

response in terms of physical sense,

ability to appreciate, orgasm, stay in

the moment, but not enough to cause like

paranoia or you know, things like that.

>> Munchies.

>> Munchies.

>> Um true for men and women or just women?

>> Both.

>> Interesting. Um let's talk about

pregnancy for a minute. Um what is

happening to a woman's arousal during

pregnancy? Again, if you go back to my

naive evolutionary view,

now I can modify my view, by the way. So

my view would have been a pregnant woman

should not want to have sex at all

because any amount of penetration puts

the fetus at risk. However, based on

what you taught me a few minutes ago,

there's another reason for her to have

sex during pregnancy, which is to keep

her male partner around to protect her

and hopefully their child. So I assume

it's a balancing act of those things. So

how does that shake out in the real

world? What do we actually observe about

a woman's sexual desire during pregnancy

and what are the dos and don'ts? so

complex as you can imagine and yes that

would be the evolutionary approach to it

um from a medical perspective um because

I think it might scare some women to say

you know oh it puts the fetus at risk to

to be clear um in a healthy pregnancy in

the absence of a contraindication a

low-lying placenta a low-lying blood

vessel or a cervical insufficiency um

which we would pick up on in routine

ultrasound um sexual health sex during

pregnancy is completely safe totally

fine and has a lot of relationship and

psychosocial benefits.

>> Is there a point at which the late

enough in the pregnancy where you would

recommend a woman not have intercourse

>> in the absence of a pathology?

Absolutely not.

>> Wow. Okay.

>> Um we know that um for many women uh sex

during pregnancy can be quite intense um

in the pleasurable uh category. The

reasons for this are the

neurotransmitters, right? You have super

high levels um of estrogen and oxytocin.

So that can make for a more pleasurable

experience. Um there's more blood flow

to the genital area. So the contractions

um of the muscles are sort of more are

more intense. The blood vessels are sort

of bringing more heat to the area. Um

and then for some women, I I wish this

for all women to feel sort of safe and

supported and bonding with a partner in

pregnancy, but that's not the case for

all.

>> Post pregnancy, what do you advise your

women, assuming they've had a normal uh

well, let's start with vaginal versus

C-section. And so if a woman has had a

C-section, what do you think is the

right time for her to go back to sexual

activity pending her desire?

>> We don't change the recommendation uh

for uh when to resume sexual activity

postvaginal birth or C-section. It's 6

weeks across the board. Um that's the

time when you go see your doctor, they

check you out, they make sure everything

is well healed. It sort of sits uneasy

for a lot of people to say, "Well, gosh,

like why would why is it the same

recovery time for both? The C-section is

is so much bigger." Um, the thought

process is that by 6 weeks, you should

have uh complete healing from the

C-section in the absence of

complications. Um, and we're more sort

of from a hormonal physiologic

perspective making sure that the uterus

has shrunk, you know, down a significant

amount, that you're not at increased

risk of infection by having things in

the vagina. Um, you're a good candidate

to have contraception at that time so we

can provide you with, you know,

protection from future pregnancies. Um,

but I think from a postpartum

perspective, you know, maybe reason

number 15 why I loved your podcast and

why I love Rachel Rubin is um, she

recently published on the genital

urinary uh, syndrome of lactation, which

basically talks about the hypoestrogenic

or the low estrogen state of the vagina

postpartum and how that mimics the

pathophysiology of women in menopause.

And so for a lot of my patients who are

breastfeeding, who have high prolactin,

um who have low estrogen, I'm

prescribing them the estrogen cream that

I'm prescribing my post-menopausal women

um to sort of keep the vagina as healthy

and sort of uh moisturized as possible.

>> Does an aesiottomy affect the ability to

resume intercourse after pregnancy or is

that usually healed by six weeks as

well? The hope is that it's healed, but

unfortunately um pain from tearing in

general or epziottoies which are um to

be clear out of fashion in the absence

of an emergency um we don't do routine

epziottoies. The data is clear against

those. Um but we um we do see that any

sort of tearing or cutting that happens

um at the vagina can lead to pain which

can lead to disp prunia, pain with sex

and therefore we have you know drive

issues and sexual health issues as well.

And another thing to think about from a

postpartum perspective is how these, you

know, these insults of pain can sort of

manifest into something bigger than they

are. So initiating, you know, sort of

participating in sex before you're ready

and having a painful sexual experience

can cause tightening of the pelvic

floor, rigidity in the in the muscles,

um, and can set into motion a pain cycle

that then takes, you know, future pelvic

floor physical therapy to break that

pain cycle. You alluded to sexual

education a number of times. I have to

be honest, I'm a little naive. I don't

really know what's being taught in

sexed. Um, I don't even really remember

what I learned in sexed, although I

remember watching these really

embarrassing movies. That's on on a VCR.

That's about the extent of it. Um, but

if you were sexed, Zar uh appointed

from a top the mountain, um, how would

you design the curriculum? How would it

differ for boys versus girls? When would

you initiate it?

>> So, if if I were a queen of sexed, um I

would get away from the fear-based don't

get pregnant, don't get an STD, you

know, don't don't you're going to get

HIV sort of fear-based counseling and

really provide the

>> Aren't those things important though?

They are important but there has to be

some actual education in terms of

pleasure and anatomy and

pathophysiology.

Um this is not a podcast talking about

you know the plight of women. I have as

a mom to four boys. I am equally

committed that boys are as educated as

girls are and I care that my boys care

about the experience that their

potential f future partners might have

with them. Um, women's sexuality is

complex. It's the anatomy you cannot see

as well as you can see with men. Just

sort of the nature of the fact that, you

know, when a bunch of boys are in a

locker room, they can see other boys

anatomy. They see the differences. They

understand that that's healthy. Women

don't often see other, you know, girls

don't often see other girls vaginas um

as clearly as as, you know, boys see

other penises. And so normalizing

through, you know, the the labia, you

know, library and and realizing what's

normal and understanding the clitoreral

nerve for for both boys and girls,

thinking about safe ways to sort of

explore intimacy. If you don't provide

them withformational content such as,

you know, OMG, yes, and and teaching

them about how to explore their anatomy,

they will turn to porn. Um and we have

great data that almost all of the porn

is not healthy um for uh teens in terms

of setting expectations that are

unrealistic um both anatomical and sort

of describing you know penetrative penis

and vagina sex as the way that women

have like screaming orgasms. That's just

not accurate. And so it set expect sets

expectations for encounters that are

just not obtainable and leads to you

know disappointment and um

self-confidence issues. So, um, I'd love

to for for for the, you know, sexual

education to be informative from an

anatomical physiologic accurate

pleasure-based perspective and talk them

through how to have safer encounters.

>> You said you have four boys, so this is

obviously near and dear to your heart.

What is

um what is the way in which you're going

to communicate with your boys about this

in an environment where they're they're

growing up in a world that you, me, your

husband like we just can't relate to,

right? Like I've made this point before

I think with with Rachel in the podcast

like when I was growing up porn was a

black and white playboy or something,

right? Like it's a totally different

thing. So what what what are you going

to do and what is your advice for other

parents out there who have growing boys

>> and girls for that matter?

>> I I think I don't distinguish the

genders you know as as much. I think

that you know I think that education

about all bodies should be provided to

all people. Um and you know so first is

sort of like you know using the correct

verbiage and anatomical nomenclature. um

calling a penis a penis and you know

calling a vulva a vulva and sort of

normalizing this as a part of your

health. Um masturbation is incredibly

healthy. Um it should be done in a

private setting and this these are sort

of ex ex it's healthy and there's a lot

about shaming masturbation and how that

can result be put your child at higher

risk um for issues in the future if you

sort of shame their exploration of their

body. It's normal. It's healthy. It's a

part of your health. orgasm is healthy,

but it should be done in a private

place. Um, and sort of how you interact

like what is consent? What are the

components to consent? What does that

look like? You know, is it specific? Is

it enthusiastic? Um, is it um persist as

the activity changes? Um, is there a

timeline on it? Like thinking thinking

about all the different ways that we

think about consent and then sort of

changing the way that sort of society

allows its perceptions to to trickle in

to what we think of of in terms of

safety. So, for example, you know, as a

as a culture, we tend to say that, you

know, penetrative sex, penis and vagina,

is sort of the end all, you know, top of

the pyramid, most um intimate act you

can do with someone. Um, but condoms are

relatively are quite effective at

preventing sexually transmitted diseases

when used uh, you know, in a in a

penetrative sexual encounter. Um, people

don't really use protection when when

performing oral sex either, you know,

women on men or men on women. And so as

we see the rise of the, you know, herpes

across college campuses, this is an

intervention that we really need to talk

about. If you're at a party and you're

with someone and you want to be intimate

with them, having penetrative

intercourse with a condom on is safer

and less likely to transmit an a

sexually transmitted disease than if

you're going to perform oral sex on each

other. And so thinking about it from a

safety perspective and not a cultural

perspective um would be another sort of

key foundational change that I think

needs to happen. Um and also sex

education needs to change like what we

talk about in like did you have sex

education in college? What about grad

school? Um what about perry menopause

and menopause? There sort of needs to be

an evolving door in terms of um you know

different providers coming in and

talking and educating because our bodies

change, our physiology changes and our

needs change and this is not a like 8th

grade one hour you know split the boys

and girls talk about it kind of a thing.

Um but coming back to this specific

issue, how much of an issue is

pornography for young boys and what what

is the solution? Like it's not going to

get regulated away, right? Although

there are some states where

at least age verification is required. I

don't know how effective that is, but I

assume it's I mean that's a step in the

right direction.

>> So my strategy in general when thinking

about don't do this is always to do a

don't do this, do this. So to sort of

like introduce what you should do

instead of what you shouldn't, it's

let's introduce something healthy. So

what does a healthy sexual life look

like? Um there are, you know, the porn

industry is is, you know,

>> there are parts of it that have evolved.

There is, you know, healthier

informational videos that you can watch

if you're looking for arousal. Um, there

are healthy ways to have an orgasm and

to interact with another human being and

talking about how you, you know, bring

someone into your life that's healthy

and how you have what, you know, what

frequency is healthy for both of you and

if you're not getting that, like to what

ends do we go to get it elsewhere? And,

um, you know, what are you searching

for? Is it a dopamine release? Is it,

you know, what can we add in replace of

that neurotransmitter release that

you're looking for?

>> Is there a crisis of intimacy in young

people? I've heard this a lot, but

again, I just don't know the data. But I

keep hearing that people in their 20s

today are becoming less and less

intimate over time relative to a decade

ago, two decades ago. And uh so first of

all, I don't know if that's something

you know, but is that is there

>> I don't I I sort of have the same

anecdotal experience in my clinical

practice where I have very lonely, less

intimate 20-year-old, you know, uh women

in my practice sort of ask, you know,

and when I when I take a sexual health

history, which which I always do, you

know, I there is there is a lot lacking

there. And we could, you know, it would

be a whole another uh podcast to talk

about AI and how that's going to sort

of, you know, replace intimacy and how

we can use that for arousal and things

like that. But I think, um, it's

something to think about.

>> So, I guess maybe final final thoughts.

Um, what are you most concerned with

right now as you think about your your

your professional world and what are you

most excited about? I'm most excited

about

the new information that we have coming

in about hormone options in terms of how

we provide menopause hormone therapy and

how we treat perry menopause and the new

types of estrogen and progesterine and

how we tinker with those and moderate

those to optimize women and how they

feel. Um, this is super personalized,

super individualized medicine and we

want to do this as physicians. we love

doing this, but I think the more

research that's coming out and the more,

you know, drugs available make it really

fun to be a part of. So, that's

definitely my area of passion right now.

Um, in terms of concerns, um, do I have

to have a concern or I I guess I just

have another passion, which is that I I

um I I think we're I think the world is

changing and I think we're I think

people are ready for it. Um, I'm ready

to to push it there. You're pushing it

there. I think it's really exciting to

think about um sexual health as a part

of your health and talking about it in a

very sort of like generic safe place

from a physiologic perspective. Think

about all the people you can get on your

team to to help you, you know, sex

therapists and pelvic floor physical

therapists and how to tinker with your

hormones and behavioral interventions.

And I love thinking about couples

listening to this podcast together and

trying different things and and um you

know seeing this as you know potentially

orgasm as another biometric or you know

sexual satisfaction as another sort of

longevity lever that we pull when

improving you know the happiness and

health of our lives.

>> I think that's an awesome way to to

close this discussion and I definitely

appreciate the optimism um and lack of

pessimism around it. So, thanks again

for all of this um this insight. I

learned a lot um as is uh often the case

with podcasts. So, thank you.

>> Thank you for having me.

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